Diagnostic limitations in the treatment of cerebral aneurysms

Endovascular coiling has become a standard technique in the treatment of cerebral aneurysms. The mechanisms of recurrence are incompletely understood.

In our clinical investigations we present three uncommon cases where the pathology at the base might has been underestimated in digital subtraction or magnetic resonance angiography.

In the first clinical study rehemorrhage occurred 11 years after endovascular coiling. Before rehemorrhage occurred, serial magnetic resonance angiographies had revealed a stable situation with only a small base remnant after initial endovascular treatment. In the second clinical study, intraprocedural rupture during endovascular coiling occurred and a residual angiographic occult lesion was detected only during microsurgical clipping. In the third clinical study, we again found a residual lesion during microsurgical clipping.

We present three clinical studies were the pathology at the base might has been underestimated in digital subtraction angiography or magnetic resonance angiography. The incidence of angiographic occult residuals is unknown, but their clinical relevance may be important. Beside other mechanisms, these lesions might be the source of aneurysmal regrowth and hemorrhage (Fig. 4, Ref. 27).